The Health Insurance In-Out Network shuffle

August 3, 2009 6:55 AM

Health Insurance snafu. The In-Out Network shuffle. Am I borked?

I was recently experiencing a number of health related issues that came about suddenly and seemed to indicate the possibility of something significantly more serious than the actual cause turned out to be. To make a long story short, I saw a number of doctors in a very short period of time, all recommended by a new general practitioner who had been recommended highly by a coworker.

The new doctor was a member of my health insurance network and with each doctor that he referred me to, I first checked with the online health insurance web site to see if the doctor was listed as being In Network. Every doctor seemed to check out and up until this morning, all seemed to be well; every claim had been processed perfectly, listing only my copay as responsibility.

This morning I checked and noticed that three of the claimed had finished processing with the entire cost being forwarded to me, each stating that the health care provider was not in-network. I cannot afford the amount being billed to me and I immediately checked the website again to see if the doctor was listed as being in-network.

He is, however, upon calling my provider the friendly woman I spoke to on the phone mentioned that the claim might have been rejected because the address listed on the website differs from the address at which I actually saw the doctor (he has office hours at a different location). She forwarded the claim back to the health insurance network and said that I should check back in two weeks.

Am I screwed because of the different address on file? I was under the impression that a doctor was in- or out- of network.. the location of the procedure and service by this doctor were all at a location listed as in-network as well (since he was using the offices of my general practitioner). I asked what my options were in the event that the claims were rejected again and she said that I could file an appeal. Has anyone dealt with anything like this in the past?

posted by Raze2k to work & money (8 comments total)

Not necessarily. I've run into the same issue before. Doctor-A is in-network if he sees you at office-A. But, Doctor-A is out-of-network if he sees you at office-B. If the doctor's office runs the claim back-through under the in-network address, you should be good.
posted by Thorzdad at 7:20 AM on August 3

So, pardon my naiveté, the way this works is that my health insurance receives a claim from the doctor and then rejects the claim, prompting the doctor to send me a bill for a full amount. I can then contact the doctor who sent me the bill, explain the situation, and he can reissue the bill under the in-network address?

Thanks for your insight!
posted by Raze2k at 7:23 AM on August 3

Raze2k, you are exactly right in your comment. The doctor's office can re-submit the claim, and in my experience the billing offices at doctor's offices are usually very willing to help with this kind of thing.
posted by not that girl at 7:32 AM on August 3

Yes, absolutely!
The doctor's office will know it was denied (and why) before you do. Sometimes, they will even re-submit the claim with the corrected information on their own. Doctor's offices are well-aware of the machinations of insurance claims and how to work with the system.

Insurers receive thousands of claims a day and their systems are largely automated, dependent on specific diagnosis codes and, as you've disovered, the correct provider codes.

Definitely speak with your doctor's billing office about the denial. I imagine they'll work with you.
posted by Thorzdad at 7:37 AM on August 3

Would you recommend I wait until after the two weeks have passed and the re-filing submitted today (upon a phone call to my health insurance company) has completed processing (and presumably been rejected)?

Or should I contact the doctor's office and explain this whole situation along with the resubmission I entered over the phone?

Again, thanks so much for your help folks!
posted by Raze2k at 7:47 AM on August 3

It sounds like waiting a couple of weeks is the thing to do. Don't worry, because delays are normal and they're not going to hurt your credit score any time soon. If you're the person who will handle medical billing issues in your household, get used to this cycle of call, question, assert and wait. The doctor just wants to get paid, and the insurance company wants to avoid paying if at all possible. If you simply pay what you're billed for then they both win and you lose. Such errors are common, you will have to be your own advocate, and it will take more time than it should.

I use very little medical care, thankfully. During the past year I've had one appointment with an eye doctor and one with a dermatologist. The insurance company screwed up the handling of the derm visit, and the eye doctor's office screwed up their billing. It's frustrating, but it's normal.
posted by jon1270 at 8:03 AM on August 3

I think you're fine. You've done exactly the right thing -- gone back to the doctor, and he's done exactly the right thing in saying "whoops, let me see if I can sort this out."

There are a lot of horror stories, yes, but I've honestly had better luck with insurance companies than you'd think I would be. I once got slapped with a bill because I had had to have emergency surgery -- and everyone else involved in the surgery was on my network, but the anaesthesiologist wasn't. When I called the insurance company to ask about that, and they told me that it was my responsibility to check on these things beforehand, all I did was observe that it was kind of hard to inquire into everyone's insurance network status when you were UNCONSCIOUS because you were about to undergo an EMERGENCY OOPHRECTOMY, and the insurance rep just hestiated a moment and then said, "you're right, that's stupid. Let me take care of this. Sorry to bother you."

Delays are totally normal. Two weeks' time isn't going to affect your credit score any -- it would be more like two YEARS before things started getting you into trouble, and presumably you'll have gotten this sorted out well before then. (Something tells me that if your GP has two different addresses, that this sort of insurance foulup happens with him a lot, so he may be able to speed this along.)
posted by EmpressCallipygos at 8:30 AM on August 3

When I called the insurance company to ask about that, and they told me that it was my responsibility to check on these things beforehand, all I did was observe that it was kind of hard to inquire into everyone's insurance network status when you were UNCONSCIOUS because you were about to undergo an EMERGENCY OOPHRECTOMY...

Any time you step into an emergency room for anything, you are open to encountering exactly this messed-up problem. Hospitals typically contract-out the actual staffing of their emergency departments, so, even though the hospital is in-network, the actual physicians, etc. staffing the er may not be.
I've also heard of insurers declining payment on ambulance services because the patient didn't pre-approve the use of an ambulance.
posted by Thorzdad at 9:25 AM on August 3